Shocking news: I'm "pre-certified" but not "approved" for insurance

[KristenLe 5,979]

Is there any way you can fight it with your employer? That's so wrong!

[kmorri 1,689]

My heart hurts for you.......But I'm hoping for great news at the surgeons office.

[PayItForward 207]

My insurance doesn't cover the surgery. But like yours, it did pay for the hernia repair. It ended up costing me around $7 (for pretests and surgery instead of $12K since they did both surgeries at the same time. I used Care Credit to pay for everything.

Sorry that this has happened to you. I don't know your circumstances but it was definitely worth it for me. I'll be paying it off for a very long time but my life is so much better.

[Sajijoma 1,324]

I am so sad for you, but look at the bright side, if you can swing it, it's going to cost a lot less thrown in with a hernia repair that is covered. That means no second anesthesia charges, and they can cover the things like sponges and sutures and that stuff too. It'll bring the cost down really to just the surgeon's fees for the vsg so hopefully the surgeon will work with you to get that number as far down as humanly possible.

[beggingtobehealthy 97]

I work for a doctor. You have to call with the exact CPT codes that will be used. Tell the insurance people what codes will be used. They will tell you if you have benefits available. Then ask them if there is medical necessity is it covered? If they say yes, you need to ask for their name and a reference number. I was told I did not have benefits but the surgery would be covered due to medical necessity then when I called again they went back on everything but I had a reference number so I was able to work something out

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[Maggie Journey 126]

I work for a doctor. You have to call with the exact CPT codes that will be used. Tell the insurance people what codes will be used. They will tell you if you have benefits available. Then ask them if there is medical necessity is it covered? If they say yes, you need to ask for their name and a reference number. I was told I did not have benefits but the surgery would be covered due to medical necessity then when I called again they went back on everything but I had a reference number so I was able to work something out

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@@beggingtobehealthy, thanks for the info. In my case, even knowing it was medical necessity, they could not cover me because the "no bariatric surgery" exclusion was built into my employer's benefits policy.

[Maggie Journey 126]

The appointment with the doctor's office yesterday was phenomenal in some ways. This might get long, and I hope it's not too confusing!

Backing up: It was about a week ago when someone at BCBS first called my coordinator saying I wasn't covered for VSG. I was sure it was some error or someone reading the wrong file or something. Right away, I suggested to my staff that IF that is true (and I didn't believe it then), we could have me do the hernia repair and then just add-on the surgeon fee for the VSG and do all at once. Makes total sense, and I can see you all understand this concept here! So, I called BCBS myself to get it straightened out and they were still telling me it's all fine, medically necessary, you're covered, etc (that person didn't look deeper into the employer benefits exclusion at that time, and I wasn't aware of it). Even though I thought we were now good to go and the coordinator believed it too, since that time my surgeon was alerted to all of this by the staff, and started looking into the ability to do this "VSG-piggyback-on-the-Hernia" plan for me.

Fast forward to yesterday: I started my appointment with the coordinator and shared all the details about how I'd just learned that I'm now definitely NOT covered for VSG due to employer's exclusion buried deep within their policy somewhere. She explained that Doc has been working on the contingency plan all week long with the hospital. Next, went into examination room for weigh, go over meds, all that stuff with nurse. Next, the doctor and most of his staff met me in the hall and then led me into his office to talk, just the two of us. He explained that at our hospital, this piggyback-VSG had never been done, though he'd tried many times before and the hospital bigwigs would not budge. In my case, he was somehow able to get through to the top brass there to get it accepted as a new procedure. This may in part be because I've been through this long process for months, met every requirement, medical necessity with several co-morbidities, and we were now just DAYS away from my scheduled surgery date. I think that the urgency helped.

During our meeting in his office, my PA interrupted to say so-and-so was on the phone, did he want to take it now or call later? He kind of darted out of the office and left me there for at least 15 minutes (I figured it was some emergency). When he came back, he said that was actually about my case; they were literally still getting finance dept people at the hospital on board with the piggyback-VSG while I was there!

Because I'm their guinea pig for this, they couldn't give me a $ figure so I couldn't even comprehend if I could afford what they were trying to do. Finally, they got a figure for the VSG portion. In order to get this squared away immediately so that I could know that I'm actually getting surgery on Monday, I paid 50% of that figure with a credit card right there. If I had time, I might have looked into the Care Credit financing or something...but no time.

My entire staff was so kind and so wonderfully human about this whole thing. I felt like they genuinely cared about me, they realize how hard I've worked and how much I want and need this. We were all celebrating after we got the breakthrough with the hospital that will now allow a self-pay VSG tied together with covered hernia repair, for the first time ever. My Doc said that my case will enable more patients who really need this to be able to get it done at our hospital in the future. I actually feel really proud and excited about this.

[Christinamo7 4,041]

I am really looking forward to seeing you post from the other side of the surgery!

[KristenLe 5,979]

That's great! So happy it's working out for you! You could apply for care credit for the balance.

[kmorri 1,689]

Oh Yay!!!! So glad this was worked out!!!!

[scampbell33 88]

The appointment with the doctor's office yesterday was phenomenal in some ways. This might get long, and I hope it's not too confusing!

Backing up: It was about a week ago when someone at BCBS first called my coordinator saying I wasn't covered for VSG. I was sure it was some error or someone reading the wrong file or something. Right away, I suggested to my staff that IF that is true (and I didn't believe it then), we could have me do the hernia repair and then just add-on the surgeon fee for the VSG and do all at once. Makes total sense, and I can see you all understand this concept here! So, I called BCBS myself to get it straightened out and they were still telling me it's all fine, medically necessary, you're covered, etc (that person didn't look deeper into the employer benefits exclusion at that time, and I wasn't aware of it). Even though I thought we were now good to go and the coordinator believed it too, since that time my surgeon was alerted to all of this by the staff, and started looking into the ability to do this "VSG-piggyback-on-the-Hernia" plan for me.

Fast forward to yesterday: I started my appointment with the coordinator and shared all the details about how I'd just learned that I'm now definitely NOT covered for VSG due to employer's exclusion buried deep within their policy somewhere. She explained that Doc has been working on the contingency plan all week long with the hospital. Next, went into examination room for weigh, go over meds, all that stuff with nurse. Next, the doctor and most of his staff met me in the hall and then led me into his office to talk, just the two of us. He explained that at our hospital, this piggyback-VSG had never been done, though he'd tried many times before and the hospital bigwigs would not budge. In my case, he was somehow able to get through to the top brass there to get it accepted as a new procedure. This may in part be because I've been through this long process for months, met every requirement, medical necessity with several co-morbidities, and we were now just DAYS away from my scheduled surgery date. I think that the urgency helped.

During our meeting in his office, my PA interrupted to say so-and-so was on the phone, did he want to take it now or call later? He kind of darted out of the office and left me there for at least 15 minutes (I figured it was some emergency). When he came back, he said that was actually about my case; they were literally still getting finance dept people at the hospital on board with the piggyback-VSG while I was there!

Because I'm their guinea pig for this, they couldn't give me a $ figure so I couldn't even comprehend if I could afford what they were trying to do. Finally, they got a figure for the VSG portion. In order to get this squared away immediately so that I could know that I'm actually getting surgery on Monday, I paid 50% of that figure with a credit card right there. If I had time, I might have looked into the Care Credit financing or something...but no time.

My entire staff was so kind and so wonderfully human about this whole thing. I felt like they genuinely cared about me, they realize how hard I've worked and how much I want and need this. We were all celebrating after we got the breakthrough with the hospital that will now allow a self-pay VSG tied together with covered hernia repair, for the first time ever. My Doc said that my case will enable more patients who really need this to be able to get it done at our hospital in the future. I actually feel really proud and excited about this.

Yay!! I knew something great would happen for you! Congrats! And now because of you, many others will be able to get the help that they need too!! This is wonderful!

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[Maggie Journey 126]

I'm home from surgery now. I wanted to give an update on this thread in case anyone is following this.

After I checked into the hospital on Monday morning 5/16 and was about to get prepped for surgery, The nurses' station called me over and said I had a call on their phone. It was a woman at the hospital finance department, wanting money right then! "You are self pay! You need to pay us before you get surgery!" Really? I had to explain how I'm going to surgery regardless as my hiatal hernia repair surgery is covered, and explained the fact that the last time I was at my doctor's office I paid for the VSG there in his office. She was still acting unbelieving and asked "WHEN were you at the doctor?" I couldn't remember dates at that moment, but I was getting irritated now and told her to call the surgery coordinator at my doctor's office, she will tell you everything you need to know about my payment. She calmed down a little and said she would do that. I haven't heard from them since. But seriously; calling a patient just as she's prepping for surgery?? Crazy.

Meanwhile, the surgery went really well, and I got everything done that needed to get done. My surgeon and his staff are awesome. I was also blessed with really good nursing care in the hospital. I did really well and walked the halls regularly, kept down my liquid diet, my first cream Soup, etc. I got to come home yesterday 5/17 in the afternoon. It was so nice to get some real sleep in my bed.